The versatile DIEP flap: its use in lower extremity reconstruction

doi:10.1016/j.bjps.2004.06.003

British Journal of Plastic Surgery

Volume 58, Issue 1, January 2005, Pages 2-13

https://doi.org/10.1016/j.bjps.2004.06.003 Get rights and content

Abstract

The deep inferior epigastric perforator (DIEP) flap gained widespread popularity as a free flap in breast reconstruction. It is also a versatile and reliable supply of a large amount of skin and soft-tissue, which can be used in other types of reconstruction.

We present 25 consecutive cases (28 DIEP flaps) performed in our service during the past 5 years for different indications in lower extremity aesthetic and functional reconstruction, both as pedicled or free flaps. The amount of tissue provided, its reliable vascular supply and long and adequately sized pedicles, together with its limited donor-site morbidity make it a useful alternative free flap.

Section snippets

Material methods and results

Since October 1998, 25 consecutive patients underwent soft-tissue reconstruction of the lower extremity with DIEP flaps: five of them were pedicled flaps, the rest free flaps (Table 1). In two cases, the flaps were obliquely cut and oriented so to augment the total length of the flaps, once into two different flaps, once into three, bringing the total of flaps to 28. The age of the patients ranged from 5 to 72 year, nine of them were female, 15 were male.

The indications ranged from the

Surgical technique

Harvesting the flap for lower limb reconstruction does not differ much from the traditional harvesting method described in the DIEP flap procedure for breast reconstruction.³ More attention is paid, however, to keeping all possible pedicles at their full length, maximising not only the possible skin paddle but also the anastomotic options (Fig. 1(A)). This involves not only both DIEP pedicles, but also both superficial epigastric veins, the superficial inferior epigastric pedicles and sometimes

Case 1

This 38-year-old woman in her last week of pregnancy was injured in a car accident and sustained major degloving of both lower limbs with exposure of bone and tendons over the dorsum of the right foot (Fig. 2(A)) and exposure of the tibia in the lower third of the left leg, together with a fracture of the internal malleolus (Fig. 2(B)). She was intubated at arrival and due to foetal distress underwent a caesarean section. She gave birth to a healthy 2.5 kg boy (Fig. 2(C)). During the same

Discussion

The traditional myocutaneous inferior rectus abdominis muscle flap has been modified and popularised by Taylor⁴ to include an oblique skin island extending beyond the rectus abdominis muscle. This flap has been used as a pedicled or free flap in different clinical situations to treat various complex soft-tissue defects of the abdomen, pelvic, sacral, genital and upper and lower extremity regions until now.5., 6., 7., 8., 9. Based on one rectus muscle this flap allows for the mobilisation of a

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Cited by (71)

Redefining the vascular anatomy of the medial gastrocnemius muscle: A computed tomography angiography study
2023, Journal of Plastic, Reconstructive and Aesthetic Surgery
The medial gastrocnemius (GN) muscle flap is a historical reconstructive option in lower limb reconstruction. The flap is proximally based on the medial sural artery, and it is assumed not possible to harvest a distally based flap because of the absence of other minor pedicles. The aim of this study is to investigate the presence and the anatomy of a distal secondary pedicle given off by the posterior tibial artery (PTA).
A retrospective CTA study was performed of 120 limbs between April 2018 and June 2020. 3D reconstruction was performed to delineate the anatomy of the distal secondary pedicle, if present. The distance of the pedicle, if found, from the intermalleolar line to the patella was noted. The number of pedicles, if multiple, was documented, as well as branches to the soleus muscle and the skin.
A distal pedicle to the gastrocnemius muscle was found in 64% of limbs. The average location from the intermalleolar line is 168 mm. The branching pattern from the PTA showed an isolated vessel going to the distal medial gastrocnemius (32.8%), two branches to the medial gastrocnemius and skin (39.3%), two branches to the medial gastrocnemius and soleus (24.6%), and three branches to the medial gastrocnemius, soleus, and the skin (3.3%).
This study confirms the presence of the secondary axial distal pedicle of the GN muscle. Furthermore, this study confirms that there is a likely association between the distal medial gastrocnemius pedicle and the PTA skin perforators.
Free flaps for lower limb soft tissue reconstruction – A systematic review of complications in ‘Silver Trauma’ patients
2023, Injury
There are 12.5 million people aged 65 years and older living in the UK. The annual incidence of open fracture is 30.7 per 10,000 person-years. In females, 42.9% of all open fractures occur in patients ≥ 65 years.
Preferred Reporting for Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and the study is registered with PROSPERO (CRD42020209149). The aim was to compare the complication profiles of free fasciocutaneous flaps and free muscular flaps in patients aged over 60 years undergoing lower limb soft tissue reconstruction following an open lower limb fracture. The search strategy based on strict inclusion criteria included PubMed, Embase and Google Scholar.
15 papers were identified, including 46 patients with 10 free fasciocutaneous flaps and 41 free muscle flaps. There were 3 complications in the fasciocutaneous group (30%) and 9 complications in the muscle group (22%). There was a total of 1 secondary procedure in the fasciocutaneous group and 4 in the muscle group.
There is insufficient data to provide statistical comparison between free fasciocutaneous versus free muscle flaps for lower limb reconstruction performed in those aged over 60 years. This systematic review highlights evidence for the successful use of free tissue transfer in the older population following an open fracture injury and requiring lower limb reconstruction. There is no evidence to suggest the superiority of one tissue type over the other, with the inference that well vascularised tissue is the most significant factor impacting outcome.
The usefulness of a free thinned deep inferior epigastric artery perforator flap and measurement of the vascular pedicle length: A thin flap with a long pedicle
2022, Journal of Plastic, Reconstructive and Aesthetic Surgery
Citation Excerpt :
SCIP flaps are thin, hairless, and useful reconstruction materials with relatively short vascular pedicle.7-14 DIEP flaps have been used for breast reconstruction and other areas requiring a thick volume, taking advantage of their rich fat content, although some reports have reported that they were used for the reconstruction of thin areas by thinning them Figure 6.24-32 This study shows that individual perforators branching from the DIEA could be regarded as different vascular pedicles passing through the skin and subcutaneous fat layer so that the vascular pedicle to the skin paddle could be used as a long adipose flap; this can be freely processed unless the axial blood vessels that form the “flame” shape are damaged.
The thinned deep inferior epigastric perforator (DIEP) flap branching from the main trunk to the superolateral direction may be useful because of its long vascular pedicle. DIEP flap is used as an axial-pattern adipose flap. The vascular pedicle length of the thinned DIEP flap was investigated using originally developed software. The clinical application of the thinned DIEP flap was verified in a case series.
In 40 patients with enhanced computed tomography (CT) data, the vascular pedicle length of the longest thinned DIEP flap was simulated using the software. A free thinned DIEP flap was used in 10 clinical cases of facial or breast reconstruction.
In all simulated cases, the vascular pedicle of the DIEP branching to the superolateral direction was the longest, and the vascular pedicle could be lengthened up to 34.8% by dissecting the vessels on the fascia as a vascular pedicle. In all the clinical cases, the reconstruction of a complex form defect or reconstruction requiring a long vascular pedicle could be achieved in one stage without any perioperative complications. The intraclass correlation coefficient between simulated pedicle length and dissected pedicle length was 0.99.
Thinned DIEP flaps with long vascular pedicles could be elevated safely. Multiple adipose or muscle flaps could be combined without complications. The length of the winding vascular pedicle could be measured using imaging data using the software first developed in the present study. This software would be useful in the planning of a thinned DIEP flap and other free flaps.
The esthetic outcome of lower limb reconstruction
2020, Annales de Chirurgie Plastique Esthetique
Citation Excerpt :
The deep inferior epigastric (DIEAP) flap is not generally recommended for routine lower limb reconstruction because of its thickness. The Gent group reported optimal results with this flap in both adults [82] and children [83]. DIEAP flap and ALT flap are direct competitors for the repair of moderate-large loss of tissue in place of the LD flap in the pediatric population [84–86].
In recent years, the progress of anatomical knowledge and microsurgical techniques, in particular the development of perforator flaps, has risen the number of flaps available for lower leg reconstruction. The esthetic consequences of flap choice and harvest do have an impact on patients’ quality of life. Nowadays, more researchers evaluate the esthetic changes following lower limb reconstruction.
This review aims to summarize the available evidence on the esthetic outcome of lower limb reconstruction.
A systematic review was planned to identify the most relevant indexed articles on this subject. The search was performed on Pubmed database without date of publication limits.
All papers about reporting information about the esthetic outcome of lower limb reconstruction were selected. Case reports and the articles not including specific information about complications, secondary procedures, and outcomes were excluded. The articles were categorized according to their topic and date of publication. The full texts of all the articles were obtained and read thoroughly. The references for each article were screened to identify articles that were eventually left outside our database search.
One hundred and eight articles were retained for the definitive review. Eleven review articles were kept because they represented a good source of information. Thirty-three articles were added after reading the full texts. The articles appear highly heterogeneous and at, this stage, only a critical and qualitative analysis could be performed.
We found information about 7895 lower reconstructions, 1295 local flaps, 6546 free flaps.
The esthetic evaluation is intrinsic subjective. Many psychological and cultural factors influence both the patient and the surgeon. There is not a validated assessment tool for the esthetic outcome of lower leg reconstruction. Therefore, no quantitative analysis was performed.
Some ancient techniques are today obsolete, like the rectus abdominis free muscle flaps and perhaps free forearm flap, others are always useful, like gracilis and latissimus dorsi free flap. ALT flap is the most versatile perforator flap today available, but the SCIP flap is gaining the favor of a growing number of surgeons. Local flaps will be always performed with success but their indications should not be pushed beyond the medium-size defects. The best cosmetic outcome for each patient cannot necessarily be obtained neither with the easiest techniques nor with the most technically demanding ones. It is necessary to develop validated tools to assess the cosmetic outcome of lower limb reconstruction.
Ces dernières années, les progrès des connaissances anatomiques et des techniques microchirurgicales, en particulier le développement des lambeaux perforants, ont augmenté le nombre de lambeaux disponibles pour la reconstruction de la jambe. Les conséquences esthétiques du choix des lambeaux ont un impact sur la qualité de vie des patients. Aujourd’hui, de plus en plus on évalue les conséquences esthétiques suite à la reconstruction du membre inférieur.
Cette revue vise à résumer les preuves disponibles sur le résultat esthétique de la reconstruction des membres inférieurs.
Une revue systématique était prévue pour identifier les articles indexés les plus pertinents sur ce sujet. La recherche a été effectuée sur la base de données Pubmed sans limite de date de publication.
Tous les articles sur les résultats esthétiques de la reconstruction des membres inférieurs ont été sélectionnés. Les case report et les articles ne contenant pas d’informations spécifiques sur les complications, les procédures secondaires et les résultats ont été exclus. Les articles ont été classés en fonction de leur sujet et de la date de publication. Le texte intégral de tous les articles a été obtenu et lu attentivement. Les références de chaque article ont été filtrées pour identifier d’autres articles qui ont été exclus de notre recherche dans la base de données.
Cent huit articles ont été retenus pour la révision définitive. Onze articles ont été retenus car ils représentaient une bonne source d’information. Trente-trois articles ont été ajoutés après lecture des textes intégraux. Les articles apparaissent très hétérogènes et, à ce stade, seule une analyse critique et qualitative a pu être réalisée.
Nous avons trouvé des informations sur 7895 reconstructions inférieures, 1295 lambeaux locaux, 6546 lambeaux libres.
L’évaluation esthétique est intrinsèquement subjective. De nombreux facteurs psychologiques et culturels influencent à la fois le patient et le chirurgien. Il n’y a pas d’outil d’évaluation validé pour le résultat esthétique de la reconstruction de la jambe. Par conséquent, aucune analyse quantitative n’a été effectuée.
Certaines techniques anciennes sont aujourd’hui obsolètes, comme les lambeaux musculaires libres du rectus abdominis et peut-être le lambeau anté-brachial libre, d’autres sont toujours utiles, comme le lambeau libre du gracilis et du latissimus dorsi. Le lambeau ALT est le lambeau perforateur le plus polyvalent actuellement disponible, mais le lambeau SCIP gagne la faveur d’un nombre croissant de chirurgiens. Les lambeaux locaux seront toujours réalisés avec succès mais leurs indications ne doivent pas être mises au-delà des pertes de substance de taille moyenne. Le meilleur résultat cosmétique pour chaque patient ne peut pas nécessairement être obtenu ni avec les techniques les plus faciles ni avec les plus exigeantes techniquement. Il est nécessaire de développer des outils validés pour évaluer le résultat esthétique de la reconstruction des membres inférieurs.
Reconstruction of moderate-sized soft tissue defects in foot and ankle in children: Free deep inferior epigastric artery perforator flap versus circumflex scapular artery perforator flap
2019, Journal of Plastic, Reconstructive and Aesthetic Surgery
Citation Excerpt :
Nowadays, the DIEP flap has gained great popularity and has become a safe and reliable choice for post-mastectomy autologous breast reconstruction, mainly due to the satisfying esthetic results it brings.21–23 Moreover, it has displayed a versatile option for the reconstruction of the head and neck and upper and lower extremities, including the foot and ankle, with multiple advantages.24–30 The DIEP flap preserves the continuity of the rectus muscle and decreases the postoperative abdominal hernia or bulge.
This retrospective study was conducted to compare the outcomes between the free deep inferior epigastric artery perforator (DIEP) flap and the circumflex scapular artery perforator (CSAP) flap in reconstruction of moderate-sized soft tissue defects in the foot and ankle of pediatric patients.
From January 2004 to December 2016, 42 patients, ranging from 2 to 13 years old, underwent foot and ankle reconstruction, with a free DIEP flap in 21 cases and a free CSAP flap in the other 21cases.
All the flaps survived. No marked differences were observed in the demographics, flap size, recipient vessels, and overall early or late complication rate (p > 0.05). The CSAP group had a shorter operation time (134.3 ± 25 min vs. 202.4 ± 24.3 min, p < 0.05) and flap harvest time (29.7 ± 8.1 min vs. 52.2 ± 9.8 min, p < 0.05) than the DIEP group had. In long-term follow-up, the CSAP group showed a lower fat hyperplasia rate (14% vs. 52%, p < 0.05) and better cosmetic outcomes than the DIEP group did (p < 0.05). The functional outcomes had no marked differences (p > 0.05).
The DIEP flap and the CSAP flap are both good options for foot and ankle reconstruction of moderate-sized defects in pediatric patients. The CSAP flap has a shorter operation time and flap harvest time, a lower fat hyperplasia rate, and better long-term cosmetic outcomes than the DIEP flap does.
Supercharged deep inferior epigastric perforator flap for reconstruction of soft tissue defect after excision of giant invasive squamous cell carcinoma of the thigh in a refractory diabetic with Pseudomonas aeruginosa infection
2023, Microsurgery

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The versatile DIEP flap: its use in lower extremity reconstruction

Abstract

Section snippets

Material methods and results

Surgical technique

Case 1

Discussion

Br J Plast Surg

Oper Techn Plast Reconstr Surg

Br J Plast Surg

Br J Plast Surg

Br J Plast Surg

Br J Plast Surg

Br J Plast Surg

Br J Plast Surg

Clin Plast Surg

Deep inferior epigastric perforator flap for breast reconstruction

Ann Plast Surg

Clinical applications of the extended deep inferior epigastric flap

Plast Reconstr Surg

Vaginal and pelvic reconstruction with distally based rectus abdominis myocutaneous flaps

Plast Reconstr Surg

Posttraumatic upper extremity wound coverage utilizing the extended deep inferior epigastric flap

Ann Plast Surg

Transiliac and retroperitoneal approach for coverage of sacrogluteal defects with inferiorly based rectus abdominis muscle flaps

Plast Reconstr Surg